For more than 20
years, I personally prefer the following approach to the pineal region.
The patient is positioned in the supine position with the head fixator applied
to keep the face down with slight flexion of the neck. The table is rotated as
needed in every stage of the operation. The incision is running vertical 10 cm
blow and above the occipital protuberance in the midline. Self-retaining
retractors are used. An osteoplastic craniotomy with flap is performed with the
center of the bony flap is the torculla Herophili. The bone flap is reflected to
the neck direction. At first the pineal area is attacked subtentorially in
supracerebellar fashion. In case that, it is necessary to attack the area
supratentorially, the dura parallel to the SSS is incised. As mentioned earlier,
there is paucity of draining veins in this area. The table is rotated as needed
so as to use the gravity to assist the surgeon working without surgical trauma.
Most of the time there is no need to coagulate bridging veins. The 2 sides are
inspected and the most adequate approach is used. It happens that both sides and
the subtentorial approach are used simultaneously. After completing the
intracranial part of the operation, water-tight closure of the dura with the
bone flap returned to place.

This approach
gives an absolute control in all anatomical structures, that make the surgeon
able to attack the lesion from all the possible angles. It gives the surgeon the
alternative route to avoid damage to the venous structures and preservation of
the anatomic structures. For case demonstration, please
click here!